Dirty White Coat
Mel Herbert, MD, and the creators of EM:RAP, UCMAX, CorePendium, and the collaborators on "The Pitt" and many of the most influential medical education series present a new free podcast: “Dirty White Coat.” Join us twice a month as we dive into all things medicine—from AI to venture capital, long COVID to ketamine, RFK Jr. to Ozempic, and so much more. Created by doctors for clinicians of all levels and anyone interested in medicine, this show delivers expert insights, engaging discussions, and the humor we all desperately need more of!
Dirty White Coat
MAID: Doctors Should Not Help Patients Die
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We talk with ER doctor Matt Clark about why he believes medical aid in dying crosses a moral line for clinicians and for society. We test his claims against autonomy, real-world suffering, and a personal story of a friend who chose a planned death.
• dignity as inherent rather than earned through independence or control
• why redefining dignity can undermine equal treatment for disabled and dependent patients
• the risk to vulnerable people through normalization and eligibility expansion over time
• “slippery slope” and indication creep examples from Canada and the Netherlands
• how medical ethics changes when intent shifts from relief to killing
• doctrine of double effect and why intention matters in end-of-life pain control
• the case for better goals-of-care talks plus stronger hospice and palliative care funding
Why He Opposes Medical Aid
SPEAKER_02Uh my name is Matt Clark. Um I'm an ER doctor at a community hospital in Wisconsin. Uh spent most of my career in Wisconsin with a brief interlude at community hospitals in Tennessee.
SPEAKER_03So we've been talking medical aid and dying first on MREP and then on Dirty White Coat. And Matthew wanted to give another perspective. But why he believes this is the wrong thing for us to be doing. So we've been talking medical aid and dying in particular on dirty white coat arguments. And Matthew wanted to give another perspective. He believes that perspective is the perspective, it's pretty simple, Mel. And I think that's a good thing.
SPEAKER_02I can't believe I have to say that. And I can't believe I have to say more than that, but I will. But that's really the bottom line is that that is not our calling as physicians. We are called to heal and to help, uh, not to harm, and doctors should not intentionally kill their patients. And um I'll kind of give you three reasons, I guess, um, why I'm you know really opposed to us being involved in medical aid and dying or physician-assisted suicide or whatever you wish to call it. And maybe I'll just kind of kind of stop at each one of those those reasons and give you a chance to clarify or ask questions or uh whatever will be helpful for your listeners. So the
Dignity As An Inherent Human Value
SPEAKER_02first reason really is is the notion of dignity. And the segment on MRAMP was titled Dying with Dignity. And I really took took issue with the use of dignity in that context. Um, because in my mind, dignity is inherent uh to us as humans, and it's inherent at all points in our lives, whether we're independent or dependent, whether we can walk or speak or toilet ourselves or do some of those things people sometimes lose uh during the dying process, that dignity is inherent. It can't be taken away from us, and we can't surrender it either. And to kill someone or assist in hastening their death is to irreparably violate that dignity. We really can't define dignity in terms of someone's abilities or their autonomy or anything else, because for any quality you would use to define dignity, you can find someone out there who doesn't have that quality. So dignity has to be inherent to us as human beings. Now, that does not mean that respect for inherent dignity means that we try to squeeze every last minute of life out of someone. And I think that in your follow-up conversation with Dr. Oostlander, there was maybe a thought that this is two extremes. It's either medical aid and dying, or we're going to try to get every last moment of life out of you. And that actually is not consistent with dignity either, because it's not consistent with dignity to use disproportionate means to preserve life that in a way that only prolongs suffering or only prolongs the dying process. That is also inconsistent with dignity. But it's a grave violation of dignity to intentionally kill someone, intentionally hasten their death. And I read that essay that you and you and Bob mentioned by Ken Murray, uh, the How Doctors Die essay. And I actually agree with most of what was written there. Um, but what I didn't find in there was really any mention of physician-assisted suicide or medical aid in dying or hastening death. It was really all about how many physicians do not want the same aggressive treatments they give to their patients. And I do think that's a very important perspective. And I think that we absolutely have to do better in our in this country and in the medical establishment of having realistic expectations, realistic goals of care discussions, advanced directives. We need to appropriately fund our hospice and palliative care systems. And that's the conversation we ought to be having right now. The conversation ought not to be should we do physician-assisted suicide? Because that really just confuses the issue, and any resources that we put towards that are resources that we ought to be using to improve our hospice and palliative care system and improve our ability as physicians to communicate uh goals of care and end of life decisions. So that's really my my first concern with medical aid and dying is the violation of inherent human dignity.
Can Patients Define Dignity?
SPEAKER_03So let me ask you this question. Who defines that dignity? Is there a place for the patient to say, I define my dignity in this way? I lived this way, I had control of my life. Obviously, patients have values of my death. And I don't want to go through the normal natural process. I want to take intrinsic human beings.
SPEAKER_02What's your argument? Because you know, those values, those beliefs are held by a person. And when that when you make that person not exist anymore through physician-assisted suicide, um, those values, those beliefs also become meaningless. So, yes, we absolutely should honor, I guess, what I'll call the kind of more subjective levels of dignity, um, or you could also call values and beliefs, but we we can't honor that at the expense of intrinsic dignity.
SPEAKER_03Aaron Powell So if I can summarize, uh human dignity trumps a person's uh decision to end their life prematurely, no matter what form that life is currently in. My second really concern about physics and suicide is the way that it's human dignity trumps is a threat to the most vulnerable people among us, to end their life prematurely. It's no matter what.
SPEAKER_02It's really a threat to the vulnerable in two lives currently in. Um and the first has to do with kind of what we talked about earlier, which is the harms of redefining of redefining dignity. Because if we define dignity in terms of, well, I live my life a certain way, and if I lose that ability, I don't want to be alive anymore. And we validate that and say that that, you know, because of your beliefs in that way, we will cooperate in your life. What are we to say to our patients who have never had the ability to live their life in a way that some high-functioning person may have lived their life? How can those patients trust that we will treat them with the dignity they deserve when they come to the ER? And how can we even hold ourselves accountable that we are treating everyone with equal dignity when um we say to one patient that, well, you know, not being able to walk or not being able to toilet yourself is unacceptable. So I will um assist you with suicide. When on the other hand, we have patients who come into the ER who have never been able to walk, have never been able to toilet themselves, or have lost that ability through some disease process. We can't have those two standards and be able to hold ourselves accountable for treating everyone with the dignity they deserve.
Risk To Vulnerable People
SPEAKER_02But the second way that physician-assisted suicide threatens the vulnerable is really through kind of the inevitable slippery slope and indication creep. Um and you and Bob talked about this. Um, and yes, certainly the the current state of physician-assisted suicide in the US is very restricted. Um the other side of that, as Bob alluded to, is that there are many patients who desire this who don't qualify for it. And the experience of other countries who have been doing this for longer than the US, especially Canada and the Netherlands, is that over time, what are intended as safeguards begin to be seen as unreasonable restrictions and they get eroded. So, for example, in Canada, this is no longer limited to the terminally ill. It's limited to just what they, I think, call enduring and intolerable physical and psychological suffering. And it's already planned that in March of 2027 it's going to be expanded to people with purely psychiatric diagnoses. And I think you know, you and I would agree that many patients with psychiatric diagnoses could not consent to ending their lives. In the Netherlands, they've embraced full-on euthanasia, including euthanasia of children. And they they just reported um the first euthanasia death of a child less than 12. A child less than 12 cannot consent to their death. And so given the inevitable indication creep and slippery slope of this, patients who are vulnerable have reason to fear if they could be in danger if physician assisted suicide in euthanasia expands. Now, you and Bob seem to feel that that is not coming to California or the United States. I certainly hope you're right, uh, but I fear that you're wrong.
SPEAKER_03I think that this is a very powerful argument, um, because um that indication creep does appear to occur. And I think it occurs because of how positive an experience it is for so many people. But when you say a 12-year-old dies by physician's hands, it's terrifying to us. I mean, nobody can hear that and go like, well, something has gone wrong here. So I think this idea of concern about indication creep is concerning to all of us. Um, and I think for the general public, it's kind of terrifying, particularly when we look in history of what physicians have done during uh different regimes in history, the horrible things that physicians have done.
Medical Ethics And Doing No Harm
SPEAKER_02I think my third and kind of final article for you is really involved in this and how this threatens our ability to maintain very perfect standards in our profession. But you've got another. So, really for you know over 2,000 years since the first Hippocratic ill, with which I think was in 400 BC, um, our guiding principle in medicine, our North Star, has been the sanctity of human life and not doing harm to a patient. Now, our understanding of that has evolved over time as medicine has become more effective, and we've realized that almost any medical treatment involves some degree of harm or some risk of harm. We've obviously developed more nuanced principles that balance that risk of harm with the good of a treatment. And so we have we have other things like the principle of double effect that uh I believe Jan alluded to um in the original MRAP segment uh on on physician-assisted suicide. But really, you know, all of these understandings are based on the guiding principle that we would never intend harm to a patient. And killing a patient, ending their life, is the most serious, the most final, and the most irreparable harm. So if we are going to say that it's okay to end the life of a patient in certain circumstances, then we are throwing out over 2,000 years of medical ethics. And we have to rebuild our medical ethics. We either have a choice. We either have to move forward without any kind of guiding ethical framework, which is terrifying, or we have to very quickly rebuild our medical ethics based on some new Norse star without the benefit of the 2,000 years plus of wisdom that got us here. And I guess I would ask our profession, are we ready to do that? And are we equipped to do that? And I certainly don't think that we are.
Double Effect Versus Intent To Kill
SPEAKER_01So let me go back for a second.
SPEAKER_03The concept of double effect, we actually did it on the pit as well, is where there'll be an adverse outcome that is not intended, but will almost certainly occur when you do a particular therapy. So the example we had was a cancer patient in the ear, and uh she had horrible pain and had been understating her pain because she didn't want to die too soon, but she had gotten to the point where she asked, like, can you just take away the pain now? And the docs talk about it like if we do that, it's very likely that you'll stop breathing. And she's like, I just need to get rid of this pain. So that's the doctrine of double effect that you can have this adverse effect. But that wasn't the what you were trying to achieve. You were trying to achieve pain relief, and because of the inadequate pain relief, uh, the patient will probably die sooner than they otherwise would. So I I think your arguments are really good, and frankly, a lot of these arguments are above my pay grade. This is for ethicists and physician, physician ethicists, and we should get them on the line. But I think all of your arguments are real, I think they're important. Um, I might ask you this one question, then is it physicians doing it that's really the problem? What if there was another class of practitioners?
SPEAKER_02Well, it would probably probably change the argument who knows about medical ethics changing.
SPEAKER_03Any of those arguments?
SPEAKER_02Um, I really don't think it would change the first two arguments. Human dignity is something that we shouldn't do this. Not only physicians are should respect, but really everyone should respect and recognize. And so too, protection of the vulnerable. Um, you know, we have an obligation not only as physicians, but as a society, to protect the vulnerable. And if if we as a society embrace physician-assisted suicide, regardless of whether or not a physician is involved, we still have that unique threat to the vulnerable and that terrible violation of human dignity.
SPEAKER_03You know,
A Friend’s Joyful Chosen Death
SPEAKER_03since I last recorded, you know, life imitates art. A dear friend of ours and our communities here decided to have medical aid in dying. And uh every Tuesday we meet at the pub with a group of people, big group of people, and she is sort of the matriarch and has been doing it for years. And she started to develop spontaneous fractures and had a subrechnoid hemorrhage, and she had a a cancer um that basically is replacing her bone marrow, and and her physician said, like, it's all downhill from here. So she decided that uh she would do this on Wednesday, one more day at the pub. And she was joyous, just joyous, um, to see everybody and to talk to everybody, and was making jokes about what would happen the next day, and and she went through it and went great. She was unconscious in you know, a minute and died uh 45 minutes later. And I couldn't think of a more dignified way to die, frankly. She was looking at a really horrible few months and decided that that's not what she wanted to do. So I put that out there just to say I I think your arguments are so powerful and so well thought through, but at the same time, on a practical level, I wouldn't want to get between her and the way she decided to.
SPEAKER_02Well, gosh, Mel.
SPEAKER_03Well, first of all, let me just say that I'm I'm sorry for the loss of your friends because I would choose that. Very sorry for her. What does that mean, Matthew? Help me.
SPEAKER_02And let me just say, too, that I'm I'm sorry that your friend felt like in that situation that ending her life was her best option. And I'm sorry that we as a medical establishment couldn't find a way to offer her hope by another means. And I think that, you know, if we take something away from this, our calling ought to be that we need to be able to offer hope by another means. We need to have effective, appropriately funded palliative care and hospice programs. And we need to offer people hope so that they don't feel like their only way to have a good death is to have a physician and their life.
SPEAKER_01Matthew,
Hospice, Hope, And Final Reflections
SPEAKER_01thank you for your time.
SPEAKER_03I uh think you've done a really uh side of this story incredibly articulately, and just thank you for taking the time to write to us and say there's another side of this, and I think you've presented it fantastically. Thank you.
